Cork University Dental School and Hospital - Doctoral Theses

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    An evaluation of Ireland’s water fluoridation policy
    (University College Cork, 2024) Cronin, Jodi; Woods, Noel; Harding, Mairead; Moore, Stephen; Whelton, Helen
    Introduction Community water fluoridation (CWF), the controlled addition of fluoride to the water supply, is an approved preventive oral health intervention to reduce the prevalence and severity of dental caries (dental decay). Celebrated for its role in reducing dental caries, it is recognised as one of the ten great public health promotion measures of the 20th century. Today, 60 years since fluoride was first added to the public water supply in Dublin, 71% of the Irish population have access to fluoridated water, emphasising the lasting influence of CWF as a fundamental aspect of public health in Ireland. This thesis aims to comprehensively assess the economic and oral health implications of Ireland’s CWF policy within the context of the nation’s hybrid oral healthcare system. This system, operating in parallel to the main healthcare system, combines public and private service provision, with most individuals paying out-of-pocket fees to independent dental practitioners. Methods The thesis explores historical, contextual, and methodological landscapes to provide a comprehensive understanding of the Ireland’s CWF policy and its implications for public health policy. To address the gaps in the evidence relating to CWF in the Irish setting, three studies were undertaken. The first study described in Chapter 6, critically appraises the methodological conduct and reporting quality of economic evaluations (EEs) of CWF. Guided by established principles for reviewing economic evidence, the study assesses the economic evidence using reliable quality appraisal instruments, specifically the Consensus on Health Economic Criteria list (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS). Chapter 7, presents an economic evaluation of CWF for schoolchildren, the first formal assessment of its cost-effectiveness in the Irish setting since the adoption of the policy in 1964. Following traditional economic evaluation methods and using epidemiological data from a representative sample of schoolchildren with and without lifetime exposure to CWF, a cost-effectiveness analysis (CEA) is performed from the health-payer perspective. The third study, presented in Chapter 8, examines the long-term effects of exposure to the Ireland’s CWF policy on dental caries among adults. The study uses epidemiological, demographic, and sociological data from adult residents of the Republic of Ireland (Ireland) with lifelong exposure to a CWF policy and adults in Northern Ireland without exposure to CWF. Negative binomial regressions are employed to estimate the relative risks of various explanatory variables, including CWF exposure, on dental caries experience among adults. Results Collectively, the results of these three studies provide a more comprehensive understanding of the effects of Ireland’s CWF policy on oral health outcomes. Chapter 6, highlights persistent misunderstandings in valuing consequences within cost-benefit analyses of CWF. The study also identifies shortcomings in the measurement and valuation of costs and outcomes across all evaluation types. Moreover, it reveals methodological subtleties that may not be discerned by the quality assessment instruments, such as accurately estimating the impact of fluoridation and the inclusion of treatment savings within cost estimates. This chapter provides valuable insights into the existing economic evidence of CWF, helping policymakers effectively leverage it to inform resource allocation decisions. Additionally, it may serve as a resource for researchers, facilitating improvements in the methodological rigor and reporting standards of future EEs of CWF. In Chapter 7, compelling economic evidence highlights the imperative of maintaining public provision of CWF for schoolchildren despite the current environment of multiple fluoride sources. CWF as a health intervention provides a reduction in the national disease burden and offers cost-savings to the health-payer, which in Ireland, is often the private individual. The findings presented by the analysis in Chapter 8, reveals that adults, exposed to a CWF policy for most of their lives, show a significantly reduced dental caries experience compared to individuals of similar age with no exposure. Furthermore, exposure to the CWF policy emerges as the most influential variable affecting caries outcomes when compared to the other variables examined in the study. Conclusions The mandatory legislation surrounding CWF in the Irish context has been instrumental in ensuring widespread access to the benefits of this preventive measure. The findings of this thesis affirm that Ireland’s CWF policy has not only been the cornerstone of its preventive oral healthcare strategy but also a steadfast pillar of the publicly funded oral healthcare service. Despite the challenges posed by a fragmented and underfunded oral healthcare system that has yet to be fully integrated into the broader healthcare agenda, the CWF policy has reliably maintained the population’s oral health since its introduction in 1964. This highlights the policy’s critical role in mitigating the negative impacts of systemic shortcomings while also demonstrating its capacity to drive enhancements in oral health outcomes for all members of the community. By providing a consistent and accessible source of fluoride through the public water supply (PWS), CWF offers a cost-effective and broad-reaching intervention to improve oral health outcomes. The findings of this thesis emphasise the significance of CWF as a public health measure in reducing the prevalence of dental caries and health inequalities, supporting its continued implementation as a public health strategy.
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    Caries and developmental defect of enamel prevalence in adults with cystic fibrosis
    (University College Cork, 2024) O'Leary, Fiona; Hayes, Martina; Burke, Francis M.; Roberts, Anthony; Health Research Board; Cystic Fibrosis Ireland
    Objectives This research had five objectives. 1. To evaluate the available literature regarding oral disease in people with cystic fibrosis specifically caries and developmental defects of enamel. 2. To ascertain the current practices and attitudes of dental practitioners regarding the provision of oral care for people with cystic fibrosis. 3. To ascertain the current practices and attitudes of dental practitioners regarding the provision of dental treatment pre and post solid organ transplantation. 4. To assess a cohort of people with cystic fibrosis for the presence of developmental defects of enamel and compare the results with a control group of people without cystic fibrosis. 5. To measure caries experience in a cohort of people with cystic fibrosis and compare the results with a control group of people without cystic fibrosis.   Methods Objective 1 A systematic review of the available literature was conducted for caries experience in people with cystic fibrosis. A second systematic review was conducted assessing the prevalence of developmental defects of enamel in people with cystic fibrosis. Objective 2 & 3 A questionnaire was developed following PPI (patient and public involvement) with representatives of the dental profession and patient advocates from Cystic Fibrosis Ireland. The questionnaire consisted of 56 questions and multiple-choice questions related to cystic fibrosis manifestations and management, dental health certification for solid organ transplantation, and the dental management of people with cystic fibrosis and recipients of solid organ transplants. Dentists were invited to complete the anonymised survey online. Data was collected from 135 dental practitioners. Data was qualitatively analysed. Objective 4 & 5 A total of 92 people with cystic fibrosis and 92 people without cystic fibrosis were recruited for this cross-sectional study. Each participant completed the World Health Organisation's ‘Oral Health Questionnaire for Adults’. Individuals with cystic fibrosis in the study group completed additional questions specifically related to cystic fibrosis diagnosis, treatment and management. All participants underwent an oral examination, performed by two calibrated examiners to assess for the presence of developmental defects of enamel (DDE index), to measure caries experience (DMF) and other clinical variables (periodontal assessment using the CPI-modified index, and oral hygiene status using the Greene–Vermillion index). Collected data was statistically analysed with help from statisticians from the Cystic Fibrosis Registry of Ireland.   Results Objectives 1 Studies included in the systematic review demonstrated a trend that caries levels in paediatric populations with cystic fibrosis are lower when compared to a population without cystic fibrosis. Caries levels are higher in adults with cystic fibrosis when compared to populations without cystic fibrosis. Similarly, the majority of included studies indicate that people with cystic fibrosis have a higher prevalence of developmental defects of enamel. Objective 2 & 3 Twenty-four percent (n=32) of dental practitioners were currently providing care for people with cystic fibrosis, 13% (n = 17) did not know, and 63% (n = 85) were not currently providing care for this population. 72% (n = 97) of respondents reported that they were comfortable treating people with cystic fibrosis, 28% (n = 38) said that they were not comfortable treating these patients. Thirty four percent of respondents currently or had previously provided care for recipients of solid organ transplants. 29% (n=36) of dentists had provided dental health certification for individuals undergoing transplantation, only 11% (n=4) had received correspondence or guidance from the patient’s medical team. 88% of respondents consider the currently available literature providing guidance for the provision of dental health certification inadequate. Objective 4 & 5 Sixty-four percent (n=59) of people with cystic fibrosis had developmental defects of enamel, compared to 30% (n=28) of people without cystic fibrosis. The median number of teeth affected by enamel defects in the study group was 1.5, compared to 0 in the control group. The percentage of people with cystic fibrosis with untreated dental caries present was 38% (n=35) compared to 13% (n=12) of people in the control group. The mean DMFT values were higher in the study group compared to the control group but only the decayed value (DT) was statistically significantly higher (0.99 vs. 0.18; (p= <0.001)). Conclusions Objective 1 While there is not a unanimous agreement across all studies, there is a consistent pattern that the prevalence of enamel defects is higher in people with cystic fibrosis compared to individuals without cystic fibrosis. While a pattern emerged that children with cystic fibrosis had lower levels of dental caries compared to healthy children, adults with cystic fibrosis had higher levels of caries compared to adults without cystic fibrosis. Objective 2 & 3 The results from the survey indicate a wide variety in the knowledge, attitudes and practices of dental practitioners regarding the oral health of people with cystic fibrosis. Similarly, the data indicates a wide variation in the provision of treatment for patients undergoing or in receipt of a solid organ transplant. There are currently no guidelines for the provision of dental treatment for people with cystic fibrosis or people pre/post solid organ transplantation. Future research should focus on the development of such guidelines to aid dental practitioners and ensure that patients receive an appropriate standard of care. Objective 4 & 5 In this study the cohort of adults with cystic fibrosis had a higher DMFT when compared to a control population without cystic fibrosis. Adults with cystic fibrosis had a statistically higher prevalence of developmental defects of enamel compared to the control group.
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    Perceptions of Class II malocclusions
    (University College Cork, 2024) Brosnan, Sinead; Millett, Declan
    Aims • To investigate if Oral Health Related Quality of Life (OHRQoL), self-esteem and perception of orthodontic aesthetic treatment need differ in children/adolescents with Class II division 1 malocclusion (II/1M) compared to children/adolescents with Class II division 2 malocclusion (II/2M). • To investigate if perceived OHRQoL, perceived self-esteem and perception of orthodontic aesthetic treatment need differ in parents of children/adolescents with II/1M compared to parents of children/adolescents with II/2M. • To investigate if OHRQoL, self-esteem and perception of orthodontic aesthetic treatment need are associated in children/adolescents and their parents, separately and across II/1M and II/2M groups. • To investigate if family impact differs for children/adolescents with II/1M compared to those with II/2M. Materials and Methods Following ethical approval, 240 individuals were invited to participate, 120 children/adolescents aged 10-16-years (60 with II/1M and 60 with II/2M) and 120 parents. Subjects were recruited from treatment waiting lists in a publicly funded orthodontic service. Informed consent/assent was obtained from each child/adolescent and their parent. Children/adolescents completed a generic (Child Oral Health Impact Profile, COHIP) and a condition-specific questionnaire (Malocclusion Impact Questionnaire, MIQ) to assess OHRQoL, a self-esteem questionnaire (Child Health Questionnaire- Self-Esteem component, CHQ-SE) and self-assessed orthodontic aesthetic treatment need (Index of Orthodontic Treatment Need- Aesthetic Component, IOTN-AC). A parent of each child/adolescent completed the parent version of COHIP, assessed the family impact of their child’s oral health (Family Impact Scale, FIS), completed the parent version of CHQ-SE and rated their child’s orthodontic aesthetic treatment need (IOTN-AC). Demographic and clinical variables were also recorded for each child/adolescent which included age, child/parent gender, socioeconomic status (SES), caries, dental trauma, overjet, overbite, severity of crowding, as well as IOTN both dental health and aesthetic components. ANOVA was used to investigate associations of OHRQoL, family impact and self-esteem between II/1M and II/2M groups. Perceived orthodontic aesthetic treatment need was compared between II/1M and II/2M groups using ordinal logistic regression models. P < 0.05 was considered as statistically significant. Results In children/adolescents OHRQoL, self-esteem and perception of orthodontic aesthetic treatment need did not differ significantly between malocclusion groups (MIQ p = 0.1480; COHIP p = 0.8067; CHQ-SE p = 0.9505; Child IOTN-AC p = 0.8987). There was also no significant difference in parent-reported OHRQoL, self-esteem or perception of orthodontic aesthetic treatment need or their child between malocclusion groups (Parent COHIP p = 0.2361; Parent CHQ-SE p = 0.9161; Parent IOTN-AC p = 0.3191). Comparing child/adolescents versus parents for each malocclusion, there was no significant difference in OHRQoL (II/1M p = 0.3110; II/2M p = 0.2317), self-esteem (II/1M p = 0.5585; II/2M p = 0.5) or perceived orthodontic aesthetic treatment need (II/1M p = 0.0645; II/2M p = 0.4050). Furthermore, there was no significant difference in family impact for children/adolescents with II/1M compared to those with II/2M (p = 0.3480). Increased age and female gender had a significantly negative impact on child-reported OHRQoL (p = 0.0001 and p < 0.0001, respectively) and self-esteem (p < 0.0001 and p = 0.0016, respectively), while female parent gender and SES i.e. those without medical cards, negatively influenced parent-reported OHRQoL (p = 0.0014 and p = 0.0450, respectively). SES influenced parent-reported self-esteem of their child (p = 0.0125), whereby those with medical cards reported worse self-esteem, while caries experience negatively influenced family impact (p = 0.0295). Younger age and having a medical card had a significantly negative impact on child reported perceived orthodontic aesthetic treatment need (p = 0.0365 and p = 0.0174, respectively). Child and parent perceived orthodontic aesthetic treatment need were significantly lower than clinician-reported (p < 0.05). Conclusions • There were no significant differences between II/1M and II/2M in relation to child-reported or parent-reported OHRQoL, self-esteem, perception of orthodontic aesthetic treatment need or family impact. • For each malocclusion, there were no significant difference between child/adolescent versus parent for all measures recorded. • Other variables, however, were found to impact perceptions, such as age, gender and SES. Increased age and female gender negatively impacted child-reported OHRQoL and self-esteem. Female parents and parents without medical cards reported worse OHRQoL for their child, while parents with medical cards reported worse self-esteem for their child. • Clinician-reported perceived orthodontic aesthetic treatment need was more severe than parent and child perceptions, regardless of malocclusion type.
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    Surgical exposure of the unilateral palatally impacted canine – a mixed-methods investigation
    (University College Cork, 2024) Murphy, Claire.; Millett, Declan
    Aims: • To assess the volumetric palatal tissue changes that occur with open exposure under local anaesthesia of a unilateral palatally impacted canine (PIC). • To assess the patient pain experience in the first post-operative week following open exposure of a unilateral PIC. • To investigate if a relationship exists between severity of impaction of a unilateral PIC, operator perceived difficulty, duration of surgical procedure, volume of tissue removal and post-operative pain. • To assess the patient’s knowledge, understanding including perceived benefits and risks, attitude, experience and level of involvement in shared decision-making regarding open exposure under local anaesthesia of a unilateral PIC. Materials and methods: Following ethical approval, thirty adolescents referred to the Oral Surgery Department at Cork University Dental School and Hospital (CUDSH) for open exposure of a unilateral PIC were invited to participate in the study . All participants had a unilateral PIC exposed under local anaesthesia by the same Specialist Oral Surgeon. For the first week following surgery, all participants completed the short form McGill Pain Questionnaire (SF-MPQ) and a pain diary at specified time points. To assess the volume of tissue removal, intraoral scans were recorded using a Dexis IS3800W scanner pre- and intra-operatively. Scans were imported into Geomagic Studio software and converted to mesh files. These files were then aligned and a digital model of the excised portion was generated. Volumetric measurement of the excised portion was created using Rhino 3D software. Perceived surgical difficulty was assessed by the surgeon using a 100mm VAS and a surgical questionnaire. Surgical duration was also recorded. Orthopantomograms were used to assess the severity of canine impaction using the method of Ericson and Kurol (1988). Data from all variables were then compared individually to pain data. Relationships with post-operative pain were assessed using ANOVA models with SF-MPQ (Total) as the outcome variable, and separate ANOVA models were used for each of canine grading, operator perceived difficulty, surgical duration and volume of tissue removal, with p <0.05. Approximately 10 days post-operatively, one-to-one semi-structured interviews were undertaken with fifteen of the adolescents by a trained interviewer. Interviews were recorded, transcribed verbatim and subjected to interpretive phenomenological analysis (IPA) by QDA Ltd. (Dublin, Ireland) using NVivo software. Results: The mean volume of tissue removal with open exposure of a PIC was 0.193cm3 (SD 0.064cm3). Regarding severity of impaction, the mean sector was 3.1 and the mean alpha-angle was 38.06. The mean operator perceived difficulty was 11.98mm (SD 9.94mm). The average surgical duration was 9 minutes and 12 seconds (SD 0.11 minutes). Pain peaked the night of surgery, followed by an overall decline over the first post-operative week. No statistically significant relationship was found between patient perceived pain and any of the quantitative variables (volume of tissue removal p = 0. 1921; severity of impaction p = 0.6973; operator perceived difficulty p = 0.4635 and surgical duration p = 0.3859). The qualitative analysis found that participants had a good overall knowledge of the treatment process. They expressed high levels of satisfaction with the explanations provided regarding all aspects of the surgery. Participants initially felt nervous, but anxiety dissipated when provided with reassurance from the surgeon and after administration of the local anaesthetic. In general, participants were not well versed in the causes for impaction or the possible risks of leaving a PIC untreated. Regarding shared decision-making, participants felt involved in this, along with their parents and the operator. Surgery had a minimal impact on eating, speaking and other activities. Overall, participants had more positive than negative experiences. Conclusions: • The mean volume of tissue removed during open exposure of a PIC was less than 0.2cm3. • In general, pain peaked the night of the procedure, and then had an overall reduction in the first post-operative week. • No relationship existed between severity of impaction of a unilateral PIC, operator perceived difficulty, duration of surgical procedure, volume of tissue removal and post-operative pain. • Patients had varying levels of knowledge and understanding regarding open exposure of a PIC and felt pleased with their level of involvement in the shared decision-making.
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    Diffuse reflectance spectroscopy in the identification of oral potentially malignant disorders
    (University College Cork, 2024) Fahy, Edward; Ni Riordain, Richeal; Burke, Ray
    Aims: Diffuse reflectance spectroscopy (DRS) examines the composition of tissue by analysing light reflected from inside the tissue. DRS has been applied to cancer diagnostics in liver, brain, breast and others. The aims of this study were to (i) to formulate a clinical protocol for use of DRS in diagnosis of oral potentially malignant disorder (OPMD), (ii) to explore the clinical utility for this probe in the mouth and (iii) to review the protocol and assess its potential use in clinical practice. Materials and Methods: A clinical protocol for use of the DRS probe was formulated based on literature review and clinical experience. A translational clinical research study with two groups, one with histologically confirmed OPMD (n=53) and a control group (n=27) were enrolled. All participants received DRS of mucosal surfaces, including areas of OPMD, in the mouth. The readings were then investigated to find reliable biomarkers and their accuracy to differentiate the two groups. Repeatability and reproducibility with two users were examined. Interviews were carried out with oral surgery clinicians after reading the protocol. Results: The protocol produced good results, which were grouped based on the site of acquisition. Our analysis found accuracy figures of 89% and 87% respectively for distinguishing OPMD and normal mucosa in the buccal mucosa and ventral tongue. This OPMD group was made up of mostly oral lichen planus (OLP), with small numbers of other diagnoses. (OLP n=41, oral leukoplakia n=5, others n=5) Accuracy figures for the dorsum of the tongue were poor. DRS was easy to use, quick and acceptable to patients. Repeatability was shown to be good, however reproducibility was fair. This may be due to inter-user pressure differences in the mouth. Clinicians were sceptical of this new technology, in part due to lack of evidence of clinical utility compared with biopsy. Conclusion: DRS has shown a new role in identifying oral lichen planus in the buccal mucosa and ventral tongue. This device may have poor accuracy in identifying oral lichen planus on the dorsal surface of the tongue. It has potential as a replacement for biopsy as a screening tool, however observed difficulties in clinical use preclude widespread implementation. Observed inter-user variability in the mouth has not been thus far explored in the DRS literature. Further studies are needed to confirm this observation.